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Annual Maintenance of Board Certification
Online Attestation Form Year 2009

(all fields with an * are REQUIRED)

Click  here if you prefer to fill out a paper-based Attestation Form and mail it with your payment.

Please complete the information below as you would like it to appear in our online directory of specialists:

Last Name: *
First Name: *
Middle:
Suffix:
Organization:
Department(cont):
Address: *
Address(cont):
City: *
State: *
Country: *
Zip: *
Work Phone:
FAX:
Email:
 
 
 
PLEASE READ THE FOLLOWING STATEMENTS AND CHECK ALL THAT APPLY.


PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SELECT ONE.
 
 
 
REQUIRED MAINTENANCE OF CERTIFICATION FEES FOR 2009:
Choose the appropriate fee catagory below. You will be directed to our secure online payment system to pay applicable fees after the submission of this form. All Attestions after March 31 are subject to an ADDITIONAL LATE FEE of $25.
 
 
Although you need not be a member of APA or the National Reigster to maintain your ABPP status, please check the appropriate box below.
 
APA Member
NR Member
 
PLEASE READ THE FOLLOWING STATEMENTS AND SIGN BELOW.
 

I agree that I shall advise BOT within thirty (30) days of the occurrence of the following events: my psychology license in any jurisdiction is revoked, suspended, restricted, subject to material conditions, or voluntarily relinquished; or a governmental body, the American Psychological Association, the Canadian Psychological Association or any affiliated state, provincial, or territorial association, determines that I have committed professional misconduct, or violated material rules of such body. This reporting obligation exists regardless of the pending outcome of any appeal or other proceedings related to the triggering event.

We want to advise you that if the matter you report is relatively minor, ABPP will simply note your cooperation in the reporting process. However, if that matter is major, an obligation may exist to submit it for possible review by the Ethics Committee of the American Board of Professional Psychology.

I hereby attest that the preceding statement is true, complete, and accurate to the best of my knowledge and belief.

Specialists holding multiple certifications pay no additional fees. The pre-1983 fee has been discontinued.

 

Signature (please type your signed name) : *
Date (mm/dd/yyyy) : *
   

Please review your information above. By selecting "Submit", you agree to the terms of this electronic document.